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Letters to the Editor |
and
Eugene Z. Oddone, MD, MHS,
* Departments of Psychiatry and Behavioral Sciences, Duke University Medical Center, Box 3903, Durham, NC 27710
Department of Medicine, Duke University Medical Center, Box 3903, Durham, NC 27710
e-mail: steff001{at}mc.duke.edu
Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
In the August 2006 issue of Radiology, Dr Mlekusch and colleagues (1) noted higher depression scores among patients scheduled for carotid artery stent (CAS) placement for high-grade and asymptomatic stenosis compared with patients with peripheral vascular disease scheduled to undergo percutaneous transluminal angioplasty (PTA). Depression scores dropped significantly in the CAS group 4 weeks after the procedure. The findings of this study add to literature supporting the "vascular depression hypothesis" that links cerebrovascular disease to emergence of depression (2,3).
The high prevalence (33.6%) of clinically significant depression symptoms in the asymptomatic CAS group is striking. We have examined prevalence of major depression in a population of 192 subjects undergoing carotid Doppler ultrasonography (US) as a subset of a multisite Veterans Affairs Medical Center study (4). Patients undergoing US examination were classified as being asymptomatic (n = 124), having a transient ischemic attack (TIA) (n = 36), or having acute stroke (n = 32). Ninety-eight percent of the subjects were male, and the mean age of subjects was 67 years. Eighty-five percent of the subjects were Caucasian and 15% were African-American. Overall, 20.83% met criteria for major depression. Rates of depression were 16.13% in the asymptomatic group, 27.78% in the TIA group, and 31.25% in the stroke group. Prevalence rates were higher in the symptomatic groups (TIA or stroke) than in the asymptomatic group (29.41% vs 16.13%, 
2 = 4.70, df = 1, P = .04).
Our rate of major depression in the asymptomatic group is consistent with the high levels of depression symptoms reported by Dr Mlekusch and colleagues. These results lead us to wonder whether we need to change our thinking about whether "asymptomatic carotid stenosis patients" are, in fact, "asymptomatic." These studies support the notion that presence of depression symptoms may indicate significant carotid stenosis and possibly cerebrovascular disease in otherwise asymptomatic patients referred for further carotid artery evaluation and treatment. Depression may improve, as shown by Dr Mlekusch and colleagues, thus highlighting the ongoing need for clinicians to monitor depression symptoms when caring for patients suspected of having or confirmed to have carotid stenosis.
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Department of Internal Medicine II, Division of Angiology, Medical University Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
e-mail: wolfgang.mlekusch{at}meduniwien.ac.at
Before responding to their letter to the editor, we thank Dr Steffens and colleagues for their thoughtful comments, and we appreciate the attention that our work has received (1).
According to current guidelines, carotid artery stenosis is considered as asymptomatic if typical signs of ischemia are missing. Dr Steffens and colleagues discuss the need for changing our current classification of asymptomatic or symptomatic carotid artery stenosis. First of all, we fully agree with the authors for two reasons. In contrast to other vascular territories, narrowed carotid arteries are restored only due to proved relative-risk reduction. Second, the course of neuropsychological symptoms or cognitive impairments as a result of chronic cerebral malperfusion are not or are just rarely taken into account as an indication to refer patients to recanalization procedures. Such neuropsychological deficits may not be as apparent as neurological handicaps but can be similarly disruptive to daily activities and quality of life. Therefore, improvement of neurocognitive function in patients with atherosclerosis should be considered as a major therapeutic goal in recanalization of carotid arteries.
By scanning the literature, we have found that obvious ischemic lesions are not common among patients with carotid artery stenosis. Clearly less than 10% of patients have ischemic lesions on computed tomographic (CT) scans, although the overall percentage maybe influenced by the duration of the follow-up period (2,3). Vice versa, only 15%–20% of patients with proved ischemic strokes had stenotic lesions in the carotid arteries (2,4).
Narrowed carotid arteries have been found to be associated with clearly impaired cognitive function (5), presumably on the basis of the induced global cerebral hypoperfusion, which may result in ischemic injury without clear evidence of infarction (6).
Unfortunately, there is little, and mainly inconsistent, literature on the neuropsychological course in patients after respective revascularization procedures (7).
In conclusion, the raised question if asymptomatic carotid stenosis really exist seems therefore more than plausible, and the answer is most definitely no. However, future studies aiming for more than just neurological signs of impairment are urgently needed before postulating a shift with regard to a long-established paradigm.
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